Low Vision Calgary Clinic - Bioptic Telescopes/Side Awareness Glasses/E-Scoop Driving
Referral Form for Advanced Low Vision Devices
FREE Phone Consultation with Low Vision Optometrist-Optometrist
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Have you been to Rockyview Hospital Sight Enhancement Clinic?
Yes
No
If Yes, Date attended Rockyview Hospital Sight Enhancement Clinic ?
Have you been to CNIB Calgary?
Yes
No
Have you been to Vision Loss Rehabilitation Calgary?
Yes
No
Are you aware of what condition has caused your low vision?- Select all that apply
Macular Degenration Dry
Macula Degenration Wet
Diabetic Retinopathy
Retinitis Pigmentosa
Other
Are you looking for improvement in your vision for distance, intermediate, near? - Select all that apply
Distance- Watching TV
Intermediate - Computer
Near - Reading
All of them
Other
Are you interested in any of these devices? - if known
Bioptic Telescopes
E Scoop Glasses
New Electronic Devices and Virtual Reality Devices
Vision Buddy
OrCam
AI Smart Glasses or AI Smart Apps
Name of Ophthalmologist (Eye Surgeon) you have seen previously? (if know)
Any Comments
Any Documents or Previous exams you wanted to share with us before the appointment
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